Obstetrics Early Pregnancy: N&V, Hyperemesis Gravidarum, Ectopic Pregnancy, Miscarriage, Molar Pregnancy & Abortion Flashcards
In a uterine pregnancy, how will the hCG change?
How does this differ for an ectopic or miscarriage?
Will DOUBLE every 48 hours
This will NOT be the case in an ectopic or a miscarriage
If there is a rise of >63% hCG after 48 hours, what does this indicate?
Likely to indicate intrauterine pregnancy
If there is a rise of <63% hCG after 48 hours, what does this indicate?
May indicate ectopic pregnancy
If there is a fall of >50% hCG, what is this likely to indicate?
Miscarriage
What is an ectopic pregnancy?
When a pregnancy is implanted outside the uterus.
Where is the most common site of ectopic pregnancy?
Fallopian tube
Risk factors for ectopic pregnancy?
- Previous ectopic
- Previous PID
- Previous surgery to fallopian tubes
- Intrauterine devices (coils)
- Older age
- Smoking
What type of contraception can increase risk of ectopic pregnancy?
Intrauterine devices (coils)
When do ectopic pregnancies typically present?
6-8 weeks gestation
What should you always ask about in women presenting with lower abdominal pain?
- Possibility of pregnancy
- Missed periods
- Recent unprotected sex
Classic features of ectopic pregnancy?
- Missed period
- Constant lower abdo pain in L or R iliac fossa
- Vaginal bleeding
- Lower abdominal or pelvic tenderness
- Cervical motion tenderness (pain when moving the cervix during a bimanual examination)
It is also worth asking about:
- Dizziness or syncope (blood loss)
- Shoulder tip pain (peritonitis)
What gynaecological problem can shoulder tip pain indicate?
Ectopic pregnancy
What causes shoulder tip pain in an ectopic
The fallopian tube can rupture. Internal blood can collect under the diaphragm, leading to nerve irritation
1st line investigation in all women with abdominal or pelvic pain?
Pregnancy test
1st line imaging investigation in potential ectopic?
Transvaginal US
What may be seen on an US in an ectopic?
- Gestational sac containing a yolk sac or foetal pole may be seen in a fallopian tube
- Sometimes non-specific mass may be seen
- Mass containing an empty gestational sac –> blob sign, bagel sign, or tubal ring sign (all referring to same appearance)
- Mass representing a tubal ectopic pregnancy moves separately to the ovary –> Mass may look similar to a corpus luteum BUT this would move with the ovary
- Other features that may indicate ectopic:
- Empty uterus
- Fluid in uterus (may be mistaken as gestational sac) –> pseudogestational sac
Management of ectopic?
Termination
Termination options in ectopic?
1) Expectant –> awaiting natural termination
2) Medical –> methotrexate
3) Surgical –> salpingectomy or salpingotomy
What drug is used to terminate ectopic pregnancies?
Methotrexate
Following treatment with methotrexate, how long should you not get pregnant for?
3 months (teratogenic)
What is the criteria for EXPECTANT management of an ectopic (i.e. instead of surgery)?
1) Ectopic needs to be UNRUPTURED
2) Adenexal mass <35mm
3) No visible heartbeat
4) No significant pain
5) HCG level <1500 IU/l
Able to return for followup
Women with expectant management need careful follow up with close monitoring of hCG levels, and quick and easy access to services if their condition changes.
Criteria for METHOTREXATE management of an ectopic (i.e. instead of surgery)?
1) Ectopic needs to be UNRUPTURED
2) Adenexal mass <35mm
3) No visible heartbeat
4) No significant pain
5) HCG level <5000 IU/l
6) Confirmed absence of intrauterine pregnancy on US
Able to return for follow up
How is methotrexate given for an ectopic?
As an IM injection into a buttock
How does methotrexate work in an ectopic?
Methotrexate is highly teratogenic - halts the pregnancy and results in spontaneous termination